Percutaneous vertebroplasty--a technique to treat refractory spinal pain in the setting of advanced metastatic cancer: a case series.

We present three cases of severe movement-related spinal pain in patients with advanced metastatic carcinomas successfully treated with percutaneous vertebroplasty (PV). These patients had multi-symptom burden and progressive metastasis. Their movement-related pain was incapacitating and refractory to a variety of more conservative interventions. PV is a minimally invasive technique to stabilize vertebral compression fractures, thereby decreasing spinal pain in this setting. Its use in the setting of advanced cancer with severe movement-related pain has not been previously clarified in the palliative care literature. In summary, PV is a technique with a favorable risk: benefit ratio even in the setting of advanced metastatic cancer. The keys to successful utilization of PV in this patient population are careful patient assessment and selection as outlined in the report, in addition to an experienced care team approach.

Percutaneous vertebroplasty in vertebra plana secondary to metastasis.

Severe vertebral body collapse secondary to metastatic disease is considered a contraindication to vertebroplasty by most authors. Resolution of radicular pain after vertebroplasty is also not well reported. A case of successful vertebroplasty of a severe T7 collapse secondary to metastatic thymic carcinoma with an associated posterior cortical fracture of the body that resulted in resolution of axial and radicular pain is described. The patient had near-complete relief of severe axial and radicular pain. Postoperative imaging revealed anterior placement of the cement without leak into the spinal canal or the intervertebral foramen. The objectives are to describe the clinical and radiographic features of the case to support the idea that vertebra plana secondary to metastatic disease may not be a contraindication to vertebroplasty in selected patients. Simple techniques to avoid leak of cement into the spinal canal are also described. Severe vertebral collapse secondary to metastatic fractures may not be a contraindication to vertebroplasty, provided that appropriate measures are taken to place the trocars and to avoid extrusion of cement into the spinal canal.

Epidural and intrathecal analgesia is effective in treating refractory cancer pain.

The use of neuraxial (intrathecal and epidural) analgesia has been suggested in treatment guidelines put forth for the treatment of refractory cancer pain. We review the literature and present our algorithm for using neuraxial analgesia. We also present our outcomes using this algorithm over a 28-month period. We used neuraxial analgesia in 87 of 4,107 patients, approximately 2% of those seen for pain consultation. Evaluation of those patients at an 8-week follow-up revealed improved pain control. After institution of neuraxial analgesia, there was a significant reduction in the proportion of patients with severe pain (defined as a "pain worst" score in the severe range of 7-10), from 86% to 17%, noted to be highly statistically significant. At follow-up, numerical pain scores decreased significantly from 7.9 +/- 1.6 to 4.1 +/- 2.3. No difference was noted between the intrathecal and epidural groups. Oral opioid intake after instituting neuraxial analgesia revealed a significant decrease from 588 mg/day oral morphine equivalents to 294 mg/day. At follow-up, self-reported drowsiness and mental clouding (0-10) also significantly decreased from 6.2 +/- 3.0 and 5.4 +/- 3.4 to 3.2 +/- 3.0 and 3.1 +/- 3.0, respectively. This retrospective review shows promising efficacy of neuraxial analgesia in the context of failing medical management.